Intoeing

Intoeing is a condition characterized by internal rotation of the foot relative to the longitudinal axis of the leg. It is typically caused by one or more benign, self-limited conditions (i.e., metatarsus adductus, internal tibial torsion, and/or femoral anteversion). These conditions typically manifest at different ages, with metatarsus adductus appearing in the first year of life, internal tibial torsion between 1–3 years of age, and femoral anteversion between 3–6 years of age. A pigeon-toed stance is characteristic; additional clinical features vary by cause and may include a curved foot or W-sitting posture. Diagnosis is clinical and based on a focused history and physical examination that includes clinical measurements for intoeing. Imaging and/or referral to pediatric orthopedics is indicated if there are red flags for pathological causes of intoeing (e.g., cerebral palsy or DDH) or if common causes of intoeing persist past the expected age range. Management for most children consists of observation and reassurance, as benign rotational intoeing typically resolves spontaneously with age.

Benign causes of intoeing ^[1]

• Metatarsus adductus
• Internal tibial torsion
• Femoral anteversion

Pathological causes of intoeing ^[1][2]

• Congenital and developmental conditions
  • Talipes equinovarus
  • Skewfoot
  • Developmental dysplasia of the hip ^[3]
• Metabolic or congenital bone disease
  • Rickets
  • Blount disease
  • Osteogenesis imperfecta
• Neuromuscular conditions
  • Cerebral palsy
  • Muscular dystrophy
  • Spina bifida
• Acquired structural conditions
  • Previous fracture or orthopedic procedure ^[4]
  • Slipped capital femoral epiphysis ^[3]

Focused history ^[3][4][5]

• Past medical and family history
  • Birth history (e.g., breech presentation, traumatic or prolonged delivery, preterm birth) ^[3][4]
  • Risk factors for developmental dysplasia of the hip (DDH)
  • Developmental history (e.g., developmental delay)
  • Past history of fracture or orthopedic procedure
  • Chronic conditions ^[4]
  • Family history of intoeing ^[3][4]
• History of present illness
  • Timing of onset (e.g., since birth or walking, sudden onset) and progression
  • Appearance
    • Pigeon-toed stance
    • W-sitting and/or egg-beater gait when running ^[5]
  • Functional impairment (e.g., clumsiness, tripping, falling)

Focused physical examination ^[3][4][5]

Review the patient's pediatric growth chart and perform the following:

• Observation of casual walking gait
• Visualization of hips and legs while standing and lying down ^[4][5]
• Palpation of the lower extremities ^[4]
• Range of motion assessment of the hips and lower extremity joints
• Neurological examination
• Hip instability maneuvers for DDH in infants
• Assessment for leg length discrepancy ^[4]

Red flags ^[1][3][4][5]

Red flags for pathological causes of intoeing that require further evaluation and/or intervention include the following.

• Clinical features
  • Pain, swelling, and/or tenderness ^[1][3][4]
  • Delay or regression in motor development
  • Abrupt symptom onset
  • Functional impairment (e.g., severe tripping or falling, limp) ^[6]
• Examination findings
  • Abnormal linear growth ^[4][7]
  • Abnormal neurological findings (e.g., spasticity, weakness, asymmetrical tone)
  • Leg length discrepancy
  • Rigid foot deformity
  • Unilateral or asymmetric intoeing
  • Limitations in joint range of motion

Approach ^[1][3][4][5]

• Red flags for pathological causes of intoeing: Further evaluation (e.g., x-rays, referral to orthopedic surgery) is indicated.
• Benign intoeing is diagnosed with clinical measurements for intoeing.

Imaging is not indicated for benign intoeing in children < 8 years of age. ^[6]

Clinical measurements for intoeing ^[4][5][8]

The following measurements are used to confirm intoeing and localize the level of involvement.

• Rotational profile assessment
  • Foot progression angle (if ambulatory): A negative value confirms intoeing.
  • Prone pediatric hip rotation measurements (i.e., internal hip rotation and external hip rotation): to assess for femoral anteversion
  • Thigh-foot angle (preferred) and transmalleolar angle: to assess for internal tibial torsion ^[8]
• Heel bisector line: to assess for metatarsus adductus

• Educate caregivers that benign intoeing is caused by physiological variants and typically resolves with age.
• Evaluate routinely at well-child visits for indications for referral to pediatric orthopedics:
  • Red flags for pathological causes of intoeing
  • Common causes of intoeing that persist beyond the expected age range

Shoe inserts, bracing, and surgery are not indicated for benign intoeing in children < 8 years of age. ^[6]